The Health Care Utilization and Medical Costs in Long-Term Follow-Up of Children Diagnosed With Leukemia, Solid Tumor, or Brain Tumor: Population-Based Study Using the National Health Insurance Claims Data

Abstract

Background: Childhood cancer survivors are at a high risk of medical consequences of their disease and treatment. There is growing information about the long-term health issues of childhood cancer survivors; however, there are very few studies describing the health care utilization and costs for this unique population. Understanding their utilization of health care services and costs will provide the basis for developing strategies to better serve these individuals and potentially reduce the cost.

Objective: This study aims to determine the utilization of health services and costs for long-term survivors of childhood cancer in Taiwan.

Methods: This is a nationwide, population-based, retrospective case-control study. We analyzed the claims data of the National Health Insurance that covers 99% of the Taiwanese population of 25.68 million. A total of 33,105 children had survived for at least 5 years after the first appearance of a diagnostic code of cancer or a benign brain tumor before the age of 18 years from 2000 to 2010 with follow-up to 2015. An age- and gender-matched control group of 64,754 individuals with no cancer was randomly selected for comparison. Utilization was compared between the cancer and no cancer groups by χ2 test. The annual medical expense was compared by the Mann-Whitney U test and Kruskal-Wallis rank-sum test.

Results: At a median follow-up of 7 years, childhood cancer survivors utilized a significantly higher proportion of medical center, regional hospital, inpatient, and emergency services in contrast to no cancer individuals: 57.92% (19,174/33,105) versus 44.51% (28,825/64,754), 90.66% (30,014/33,105) versus 85.70% (55,493/64,754), 27.19% (9000/33,105) versus 20.31% (13,152/64,754), and 65.26% (21,604/33,105) versus 59.36% (38,441/64,754), respectively (all P<.001). The annual total expense (median, interquartile range) of childhood cancer survivors was significantly higher than that of the comparison group (US $285.56, US $161.78-US $535.80 per year vs US $203.90, US $118.98-US $347.55 per year; P<.001). Survivors with female gender, diagnosis before the age of 3 years, and diagnosis of brain cancer or a benign brain tumor had significantly higher annual outpatient expenses (all P<.001). Moreover, the analysis of outpatient medication costs showed that hormonal and neurological medications comprised the 2 largest costs in brain cancer and benign brain tumor survivors.

Conclusions: Survivors of childhood cancer and a benign brain tumor had higher utilization of advanced health resources and higher costs of care. The design of the initial treatment plan minimizing long-term consequences, early intervention strategies, and survivorship programs have the potential to mitigate costs of late effects due to childhood cancer and its treatment.

Keywords: brain tumor; cancer survivor; children; cost of care; health care; health resource; leukemia; long-term follow-up; population-based study; solid tumor.

Figure 1

Distribution of annual outpatient visits in the cancer and comparison groups. The probability distribution of the annual outpatient visit frequencies in each group is summarized in a histogram. The area under the curve of each group is 100% of probability. Note the long tails in the brain cancer and benign brain tumor groups. CNS: central nervous system.

Figure 2

The median annual outpatient expense in each cancer and comparison group is shown (A) and compared by gender (B) and age at entry (C). The distribution of annual outpatient expense per person was compared across the cancer and comparison groups in a box plot (D) (circles, mean annual outpatient expense; boxes, the 25th, 50th, and 75th percentile of each group; solid vertical lines, 1.5 box length, ie, 1.5 interquartile range; dots, outliers). The average outpatient medical expense per person-year in each cancer and comparison group was compared (E). Color bars represent the Anatomical Therapeutic Chemical (ATC) Classification of medications and the lowest brown bars represent nonmedication costs of medical services. CNS: central nervous system.

Figure 3

The annual outpatient expense in each cancer and comparison group was compared by male (A), female (B) and the age at entry of 0-2 years (C), 3-5 years (D), 6-11 years (E) and 12-17 years (F). Circles, mean annual outpatient expense; boxes, the 25th, 50th, and 75th percentile of each group; solid vertical lines, 1.5 box length, i.e., 1.5 interquartile range; dots, outliers.

Figure 4

The average outpatient medical expense of medications per person-year in each cancer and comparison group was compared. Color bars represent the ATC Classification of medications. ATC: Anatomical Therapeutic Chemical.